Rheumates@work: an interactive internet program to promote physical activity in children with juvenile idiopathic arthritis

Juvenile Idiopathic Arthritis (JIA) is a chronic disease in which periods of
active inflammation alternate periods of inactive disease in an unpredictable
way. In children with JIA there is some evidence of an increased risk of
premature atherosclerosis and osteoporosis. Although impairments are most
pronounced in children with active disease, deficits like fatigue, low aerobic
and anaerobic exercise capacity and decreased physical activity levels remain
long after disease control is obtained. For the present JIA patients are prone
to sedentary lifestyles and are at risk of becoming social outcasts.
In the past physical activity was thought to be harmful for children with JIA.
There is evidence that exercise testing and exercise programmes are safe,
feasible and acceptable in children with JIA. Adolescents with JIA who are more
fit feel better. Physical activity, exercise and fitness have beneficial
effects in healthy children and adolescents on growth and development. For
children with JIA the same benefits are recognised. The importance of exercise
in managing JIA is recognised and not any longer disputed. Usual care (oral
advises given by the children*s rheumatologist combined with brief counselling
by a physiotherapist) has not been effective to induce a positive change in
exercise capacity in children with JIA. Exercise and physical activity can be
seen as a type of behaviour. Therefore we expect that cognitive behavioural
therapy (CBT) could be a successful approach to improve exercise and physical
activity levels in children with JIA. A literature search on the content and
efficacy of psychological interventions for improving exercise behaviour in
children with JIA showed that no such intervention for children with JIA
exists. There is increasing evidence that cognitive behavioural therapy is
effective in managing chronic pain and to enhance quality of life in adults
with rheumatoid arthritis. Bandura's Social Cognitive Therapy en The Health
Promotion Model designed by Pender focuses on improving self-efficacy. They can
be used to develop a Cognitive Behavioural Programme to improve physical
activity in JIA patients.
The use of internet technology has provided new opportunities for treatment and
for promoting various health behaviours such as physical activity. Besides
supplying information internet is used increasingly for interventions.
Internet-based physical activity interventions can reach large number of people
at relatively low costs. Patients with JIA are scattered over a large
geographical area and therefore internet based programmes are attractive to
reach them.
A recent pilot study studying the effects of Rheumates@work showed that
children with low activity levels and low exercise capacity improved
significantly. Children as well as parents enjoyed the program and the group
sessions.

To improve physical activity levels and physical activity patterns in children
with JIA by means of cognitive behavioural training based on the social
cognitive theory and the health promotion model, delivered by internet and
supported by group sessions.

This study is a randomized controlled trial, which comprises an intervention
group and a waiting list control group. The internet-based intervention will
last 14 weeks.
Inclusion is based on the diagnosis, age and disease activity. Selection of the
definite study group is based on the exercise capacity an activity level. The
selected group will be randomised in an intervention and a control group.
Children who are not selected for the study are offered to participate in
Rheumates@work at a later stage.

The intervention is an internet based program lasting 14 weeks, combined with 4
group sessions. It comprises education, physical activity and a cognitive
behavioural training. During the intervention the child will receive standard
care for the JIA.

Physical activity and exercise are safe for children with JIA and therefore
there are no risks in participating.
During the study questionnaires are taken which is not performed in standard
treatment. This takes 4 times 1, 5 hours within one year; at the start of yhe
intervention, 14weeks later at the end of the intervention, 3 months later and
9 months later. Disease activity and exercise testing are routinely taken in
the standard care. Excercise testing will normally be performed 1-2 times a
year. In this study it will be done 4 times within one year. During the
intervention the children have to invest 2 hours on a weekly basis. We expect
that the patients will benefit directly from participating in the program.